Telehealth Authorization Form for Mental Health Services at NPAS
Student Information
Student Name
Grade
Date of Birth
School Counselor
Holgate
Willner
Bartusek
Bradley
Garcia
Erickson
Parent/Guardian
(if under 16)
Parent/Guardian
phone & email
Mental Health Provider Information
Provider Name
Provider phone &
email
Providers
Organization’s Name
Provider’s Address
Appointment Details
Day of the Week:
Time:
Consent for Release of Information:
I, the undersigned, hereby authorize my child's licensed mental health provider (or my licensed
mental health provider if I am 16 years of age or older) to release information from my health
record that is requested by the school to confirm that I am currently receiving mental health
care from the provider. This consent is valid for the school year in which it is submitted.
I acknowledge and agree to the following:
1. Validity Period: This consent is valid for the current school year.
2. Revocation: I understand that I may revoke this consent at any time by providing written
notice to the school, except to the extent that action has already been taken in reliance on this
consent.